Appendix C - Application Cover Page and Contact Information

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LEA Applicant Information

Name of LEA Applicant *

Mailing Address *

City *

State *

ZIP Code *

CD/CDS Code *

Contact Information (Person responsible for day-to-day grant oversight)

Name of LEA Contact Person *

Phone Number *

Email Address *

Title

Contact Information (Person authorized to sign grant award agreement)

Name of LEA Signatory *

Phone Number *

Email Address *

Title

LEA Fiscal Agent Information (Person responsible for grant budget oversight)

Name of Fiscal Agent *

Agency *

Mailing Address *

City *

State *

ZIP Code *

Phone Number *

Email Address *

LEA Administrative Approval

Superintendent Name *

Superintendent Title *

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